Episode 203: Dr. Joseph Yousefian, D.M.D, M.S. . A Paradigm Shift

Hi and welcome to episode 203 of the Untethered podcast. Today we have Dr. Youssefian joining us. Dr. Youssefian graduated from Washington University with postgraduate training in orthodontics with a dual Master of Science degree in Biology and Physical Anthropology at the Ohio State University. He's a diplomat at the American Board of Dental Sleep Medicine and Orthodontics and has a private practice in Bellevue, Washington. He's collaborated with several NIH funded clinical trials in the airway, open bite and TMJ disorders. He has served as a clinical Assistant professor at Ohio State University and the University of Washington in graduate periodontics and orthodontics and he is currently a guest lecturer at the University of Missouri, Kansas City. He's a manuscript and book reviewer for several publishing companies including the Permanent Day Journal and CRC Press, Taylor and Francis Group. He's a lecturer nationally. Internationally, he's served in Children Airway Screening Task Force in collaboration with American Dental Association, American Orthodontic Association, American Academy of Sleep Medicine, American Academy of Pediatrics and several other medical and dental organizations. He has contributed over 30 publications and peer reviewed journals and 12 textbooks. Quick disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Dr. Youssefian, thank you so much for joining me today on the podcast.

Thank you very much for inviting me. It's a pleasure to be here.

So I would love to jump in and have you share. I know they just heard your bio, but I want you to share in your own words. You know, what prompted you to become an orthodontist and at what point did you get involved in sleep medicine?

Well, when I was growing up this issue of the medicine always was very attractive to me and when I grew up a little bit more, 6, 7, 8, 10 I noticed that I'm very very good with my hands and you know, I was more attracted to build things, do you know, make Legos and cut things and make the, you know, small sculpture. So enjoyed working with my hand and then again the issue of the joining the medicine and somehow getting involved with medicine, it was a concept for me. And now that I'm good with my hand and I enjoy that. And then the issue of the dentistry or medicine came. Which one? So they told me that if you go to medicine, well, if you want to work with your hand, mostly is going to be probably surgeries. So it was at the time I was not very keen to just jump into the surgeries. So Denis 3 was also. Was very attractive at the time. So becoming a, you know, dentist, that was. I joined dentistry and started dental school. And then amongst everything else that I was observing at the time, meaning surgery, dentistry, restorative dentistry. This concept of moving teeth think, this concept of structure that we think that is permanent there and you cannot move it and you gradually moving it and whole reshaping the mouth of the patient and jaw of the patient became very, very attractive. At the same time, wire bending, moving teeth and everything that else that comes in with it that attracted me to the science. So that's how I joined orthodontic and how lucky I am because it's fun to do what you can find as your hobby and enjoy it too. So that's how, you know, I found this science and I'm glad that I did that.

And then were you in the sleep medicine side of it though, pretty early on, or did that come later?

Yeah, the issue of the sleep medicine, it was a necessity in life. So at the time, you know, I always was fascinated with the. When I started orthodontics and doing orthodontics, I didn't want to have a large practice, wanted to do one at the time and one to one contact with my patient. And gradually I was in the area that was very, very saturated with orthodontists. As a result of that, I had to do whatever that I could get my hand on complex cases that nobody else wants to do that and then start the TMJ case. Patients, we're suffering from the tmj, headaches, jaw pain that started coming and then gradually that build up the reputation that if you want to, you know, if you have somebody that, that has the issues with this pain and discomfort, you know, Joseph Yousefian, it seems that has some. Develop some expertise in it. So I think that gradually I was getting more and more complex cases. And of course, about 15, 20 years ago, the concept of the sleep apnea and also it Was kind of something that it was coming to the arena of Denis sleep. The concept of the sleep apnea and how the environment of the mouth and jaws and behind the airway they have so close proximity and how the sleep apnea is generated and how dentistry it can work with this population of patients and our work how is impacting the airway of the patient, especially an adult patient that I was seeing at the time as a TMJ patient that was attractive. I started treating those. But the concept of the pediatric sleep apnea was something that at that time was not so much talking about and nobody was mentioning it and bring it up too much on the lecture secrets. Then suddenly I noticed some changes that is happening on my son and only child at the I have is growing and has sign and symptoms of the problem. And hopefully we are going to have chance to, you know, talk about it later. So that and the significant problems that was happening to his life and his health, it created necessity that I need to research it. Because doctors they couldn't find out why he wakes up in the middle of the night and comes to our bed and why he cannot sleep, why he wakes up, why he clinch and grind. So as a result of that I have to work hard and do some research. And then I noticed that yeah, in early childhood sleep apnea is going to show up like this and has these symptoms. So then because of that it was not a job, it was goal of the life because I have to save my son. Because my only son was suffering from this and nobody else knew how to do it. So I made contacts and among those contacts, when I was lecturing my mentor late, unfortunately he passed away. Dr. Gimino. We got opportunity to lecture together and he opened up my eyes to the idea of sleep which I was already incorporating in my office. And also how it impacts the pediatric population. So that's how I started working on this. And of course was very bumpy road at the time we were whispering about it because. But later I'm glad now is something that everybody is talking about. That's how I got involved with the, you know, sleep medicine.

Yeah.

Necessity that I had to do it.

Yeah. I hear this time and time again that so many providers, whether it's, you know, an orthodontist, a dentist, speech pathologist, myo feeding, you know, tetra tissue release provider. Everybody seems to kind of fall into these arenas when we have our own kids and they kind of throw us down that rabbit hole of figuring out how do we help our own children. So I think that's you know, you've been doing this a long longer than I have, than some of my colleagues have. And I think it's really commendable because I know that it's, it's not an easy road now. So I can only imagine how much harder it was when you initially started this and there was all that whispering with how do we best help these children? Yeah, how early do you start working with children? Like what age?

Well, the thing is that that's something that gradually, gradually got more and more intense because at the time that we discovered this issue for my son, he was about 6, 7, 8. So and then the focus now is at, you know, at that age, you know, earlier, you know, orthodontic, what we call the field, always talk about starting the first age, starting orthodontic treatment for children is seven. So considering that, that all right, we see the patient at least at age 7. So we need to start working on them the first time that we, you know, age 7, 8. So that was the again concept for me for a period of time. But again, Dr. Gimino brought something else to my attention because in one of the lectures that I remember that in Santa Barbara we were lecturing together and I mentioned this when I started lecturing and I mentioned that as orthodontists we start at age seven and that's probably is recommended at that age. And then after the lecture, very, very nicely and you know, in fun way he brought it to my attention that especially the ADD adhd, that it can happen as one of the side effects of the disease. If by any chance we can get into it early, we can reverse the condition versus if it stays around and linger around a little bit longer, the chance of becoming a permanent situation and how impacting the life of the patient is important. Now of course at the time the problem was that we did not have the instrumentation, we didn't have the knowledge. I mean pediatric dentists, they were lucky that they see this patient at age 2, 3 and they're used to handling this patient early on. But at the same time, you know, for as orthodontists is hard. The concept of seven year old patient is difficult to manage. But then now you're getting to 5, 4, 3. So as a necessity now I need to have, I had to develop the instrumentation and the concept that we can use it on these early young children. Meaning that as soon as they have dentition, age 2 or 3 and they have the capability of handling, being around their mouth and working on them, that's how soon we are going to start if they have sleep apnea, if they don't have a sleep apnea and design and side effect of the small jaw, we just wait and treat it as orthodontic approach. But if they have a sleep apnea, that creates a red flag and necessity to get in one way or another as an interdisciplinary group to work with each other. And now of course as orthodontist, my earliest age that I'm going to show a case on that is about two and a half, three years old. That's the youngest patient that we currently have and they're coming from Houston. But at the same time to work on this population of patient, I learned that when I hear that so and so my patient has also younger brother or sister sibling that has such a problem as breastfeeding maybe is a problem or breathing or they cannot breathe. So I learned my lesson that I work start working with the myofunctional therapies or feeding, you know, coaches that they are familiar with this and then make the referral to them. So they start working on those because the patient doesn't have teeth or they have very limited number of teeth. It's just anterior front teeth that I cannot do that much with it. So start working with myofunctional therapists and they can work on this population of patient and start training them the way that they do it like specialists like yourself. And. And then when the dentition, it is more kind of a deciduous dentition and is complete, then is the time that if by any chance still they're suffering from the problem, previous training or work of the myofunctional therapist did not improve it, then I can get in and do start my early orthodontic treatment. So that's the way that handling that's fantastic.

And it's a topic that I know we love to hear about and we love to hear more, especially orthodontists saying that 7 is no longer early. Right. We need to be backing it up even more. And I've been very grateful to have both of my kids in early orthodontics. Both of them started at age 4. And part of it was because of pandemic timing, Part of it was just that's when I fell into it with my first. But the health changes for them have been incredible. And then myself as an adult with ADHD who just had the full blown nasal surgery April of last year after going through or trying to go through adult expansion, having had expansion when I was younger, my mom was told I Had ADHD when I was in preschool, she took me to three different people to assess me and didn't medicate me. But, you know, I struggled to feed as an infant. You know, it's been there. I had a tongue tie. It's been there since day one. Right. So I, you know, I'm the patient. I had two more patients and, and you know, I can appreciate this, but I, I love, like I said, I just love to hear it from an orthodontist perspective.

That's right. So, yeah, so. And I think that the best, the best experience is to have the opportunity, somebody in the family member that is right next to you and is growing up and you think that this is a kind of distance problem. Yeah, it's happening to patient. I don't suffer. But then you yourself, you are involved with it and you suffer it and, or your child is suffering from this. This is the best way of experimenting with this and learning about it because the concept is right in front of you every day. And you see, it's not like orthodontic case. They go and come back in two or three months or, you know, but there you see them every day and that's the opportunity.

Yeah, no, it's incredible. And I know we're going to, you're going to share some patient cases and I don't know if you want to talk about this first or if this will be embedded within that, but I would love to talk a bit, go a bit deeper on the issues with growth and development of the jaws and how that, you know, I talk about how a lot of this impacts feeding on my end. But I'm curious to see what you see on your end as well and how these early treatment issues then you know, alter or I guess positively change mal occlusion. You know, I had one daughter with crossbite, another one who actually had a very, very deep bite and had croup nine times last year. History of airway issues since birth, upper respiratory, all the things. And then, you know, we talk about the, the vertical growth, the gummy smile, all that fun stuff. So like I said, maybe you'll, you'll cover these things in your cases, but I would love for you to talk a bit about that.

So the issue of that, how early we need to start and how early the problem start is actually intrauterious, meaning that fetus still, even in the third trimester of the pregnancy, the problem can develop right there. Because now the science shows that there are a lot of issues there that in mother during pregnancy that you know, they can impact the growth and development of children. So these are multifactorial. One of them is the not sufficient or iron deficiency that mom suffers from that during the pregnancy. So the iron deficiency, it is going to create some issues with the growth and development of the muscles in general, and then eventually by impacting the myoglobulin, which is the component of building the muscles. If the iron deficiency is there and continue through the pregnancy, then these are the patients that they can have some hypotonia of the muscles in general. And the research shows that also it can impact what we call the muscles that they are around face, especially orbicularis oris, that is very, very important for sucking. So their research, again based on the research, this population of patients suffering from the iron deficiency or the premature babies that they have a high percentage of the hypotonia, these are the patients that have more tendency than usual to become mouth breeders. Then there are some other issues like vitamin D deficiency also that we know that it is a pandemic right now because of the vitamin D deficiency. And a lot of pregnant moms around the world, they suffer from the vitamin D deficiency and iron deficiency. So vitamin D deficiency also has an important factor on the growth and development of the bones. And patient or mom that is suffering from that, it is not unusual that, you know, the newborn, it is going to start developing some bony problems, some structural problems, skeletal problems because of the vitamin D deficiency. And also both iron and vitamin D, they have important impact on the growth and development of the cranial nerves. So early on, when this population of patients, especially premature ones, when they are growing, they're born and growing the development of the cranial nerves, they're going to be impacted. It can impact them systemically. Rickets is one of the most severe form of the vitamin D deficiency. But then it can impact also the growth and development of the jaws of the patient. Because if patient has hypotonia in general, especially in the area of our expertise, mouth, lips, muscles, they don't have the strength that they can. For example, for breastfeeding, it is going to be impacted. Starting chewing harder, food is going to be a little bit more difficult. And it starts with breastfeeding there. And of course, is multifactorial problem. Even when patient, when mom is suffering from sleep apnea herself, the lack of proper oxygenation during that time, especially for pregnant ladies or moms, that they gain a little bit more weight during pregnancy, and they develop some transitional, what we call the hypoxia because of the transitional sleep Apnea that they're suffering during pregnancy. Pregnancy, especially the last trimester. The hypoxia it can impact on the growth and development of the jaws of the newborn and fetus. Even so, of course, this is the animal research. But the research has shown that when they tried to create the experimental hypoxia in baby mouse and rats, they made a group of normal breeding group of the baby rats. And the ones that they created hypoxia, experimental hypoxia, although it was alternate. They noticed that the ones that they suffer from hypoxia they had more tendency to have a smaller gel. These are growth. And we don't know or I'm not aware of a research that right now shows that how it impact the human newborns. But we know at this point, the science shows that in animal, at least in rats hypoxia it can create some growth and developmental problems. These are the things that we need to get into it a little bit earlier. Especially if we see a sibling that is in our treatment and we see some sign and symptoms. For example, they have narrow jaws. We call it genetic, genetically narrow jaws. In some families they have narrow jaw. But now we are getting understanding the concept that is not genetic only is epigenetic environmental factor. And that epigenetic, as I mentioned, start talking about it, start in intrauterius in the second or the third trimester. And if we can consult and communicate with mom that is pregnant. And bringing her four to six year old son or daughter to us to treat sleep apnea or constricted arches is not a bad idea. As a. As you know, kind of sharing the idea. Because as orthodontist, I cannot make the diagnosis for pregnant mom that you need to check these or check this. But if you bring there to their attention that based on our experience, the narrator of Billy, for example, is not just genetic and is also epigenetic. What mom is suffering right now, maybe transitional sleep apnea. If they have it, if mom has it, or any iron deficiency, vitamin deficiency, calcium deficiency. We can advise or recommend that it's not a bad idea. Check on that and talk to your obstetrician. And they check on that and see that maybe the new or fetus mom is pregnant. Maybe we can prevent this even further. Even more ahead of time than they are born. And then now they have this deficiency. Because again, I was talking about these narrow jaws and small jaws. Because the other issue is the issue of vitamin D deficiency. Of course, in severe cases that is short of becoming disease like Rickett's disease. But Those vitamin D deficiency. Also the science shows that it can impact the growth and development of the jaws and especially maxilla or upper jaw of the patient. This population of patient hypothetically born with the vitamin D deficiency. Although in most of the advanced or civilized part of the world, they fortify the baby food and formula, even they add the vitamin D and iron and some other possible missing components. But they need to understand that and they don't assume that automatically, you know, baby is going to get that we encourage breastfeeding. And how important is the breastfeeding for growth and development of the jaws and baby and getting the nutrition from mom. But mom needs to have enough of those nutrients in blood, including oxygen, proper oxygenation, proper vitamin D, C and the rest of these, so they can feed the baby. In the other hand, the breastfeeding that we are encouraging for the growth and develop of the jaws. If the vitamins are not or nutrients are not in, it actually becomes a problem. This is not just one issue. It is the issue of the starting breastfeeding, encouraging breastfeeding. And also we should be sure that mom is healthy enough that can do that. And then of course I mentioned about being multifactorial. The issue of the tongue tie that you brought it up earlier also is another concept because for long, long time it was something unknown to orthodontists. Why do we pay attention to tongue tie? And why is it important? Not the science and especially obstetricians and midwives, they understand that baby in the last trimester, the tongue start gradually separating from the floor of the mouth and raising to the roof of the mouth. And is very important because the tongue raising to the roof of the mouth is very important for growth and development of the maxilla. So it is noticed and it is reported in literature that babies or fetus at the third trimester, when they suffer from these tongue issues, when they are born, even intrauterius with system, they can see that the jaw of these or the mandible, the maxilla of this patient is already constricted. And when they are born become obvious that they have. And the research shows that they have a little bit narrower upper jaw, especially upper jaw than normal. So those are the things that is going to be preventative. And if you're talking to our patients again, we have a patient 6, 7 years old and is suffering from the tongue tie. How early we can intercept this? If mom is pregnant, we bring it up that how important is the tongue tie and educate the family that yeah, we don't need to do the surgery Necessarily. But my functional therapist, sometimes they can encourage stretch this ligament sublingual frenulum and avoid the surgeries. But if it happens at birth for the siblings that you know, mom is pregnant with, they need to be aware of it, that right away they need to do the, you know, clipping of the tongue tie. And of course I think that it becoming rule in some countries like Brazil. I know that is a rule that definitely, you know, any tongue tie baby is born, they need to right away do it. Of course in United States the awareness is coming more and more and that's something that they do more often. So that's a good, great preventative that. So to answer your question, how early we start, we just start writing intrauterines.

And we go from I love that. No. And it's, yeah, I keep saying I hope for the day that the US catches up with Brazil with the universal tongue tie screenings at birth. Because you know, my first, my daughter's was missed until she was 24 months. I became educated in it and I diagnosed it. You know, my second one I knew right when I latched her in the hospital and, and in my course and feed the peas, I Talk, I teach OTS and SLPs about this. We talk about the in utero development, the gestational ages at which different tissues are formed and when the, you know, apoptosis should happen with the frenum, you know, lip, tongue and, and that's really these babies we find at least in our textbooks tell us that they're swallowing around 12 and a half weeks in euro right at the end of that first trimester with the swallow they're going to be born with. And so if that cell death did not happen with those frenula, we now have a baby who's already had this issue for quite some time. It's not just brand new. When they're born, they come out the birth canal or mama's belly. So I think it's a really great conversation be highlighting because it's, it's there and it starts early and we like you said, these, the tongue, if it can't rest properly in the maxilla, is not going to, you know, form the maxilla properly. And we have a whole other host of structural issues which I don't treat. But we do work with those, you know, infant toddler feeding with the soft tissue structures and you know, it's, it's fascinating because sometimes we do have those babies who are headed for a tethered oral tissue release and we're still working on the orofacial structures to help prep them for that. But then on the flip side, we sometimes have some that mimic a tongue tie because they're. They have such interesting tension patterns and compensations already in place at birth that sometimes when we get in there and we do work with the soft tissue, we're able to relax, you know, everything and they can improve feeding. And so like you said, not everybody actually needs a release per se, but there are those who do. And yeah, I just, I think we need to be talking about this more and looking at it at birth, in the hospital, at home, wherever you're birthing the baby. Like somebody needs to be doing that screening. So I really appreciate you bringing that up.

It is important because the other subject that you were talking about, myotonia of the orbicularis oriso patient that is born and you know, not even without the nasal congestion, they just become mouth breathers because or recurrence or it doesn't have enough tone to close. And this population of patients, they suffer from the again, lack of vitamin D or iron. They cannot bring their lips together like down syndrome patient or patient that are premature or they have hypotonia or muscular dystrophy. So those are the ones that, because we know that mouth breathing, it can be hand in hand with the early development of sleep apnea or upper airway resistance syndrome. So the. And then of course, you know, when they get to the, you know, older, they now started getting their teeth and the nutrition now it becomes something that orthodontist and the art and science of orthodontic that it becomes, you know, what we call crucial to get comfortable and you know, start on these cases. Although our great colleagues, pedodontists, now they are getting to the idea of early orthodontics also. So they are the ones that also they're going to be in frontier line to treat this population of patient. So as a result of that, again, as I mentioned, based on the experience and again, hit and miss and we develop the science or approach that it is going to start early treatment. So and there are some a lot of ideas that about the development of the jaws and how to grow the jaws early. Again, myofunctional therapy is the best thing that we can do. And early sort of the, you know, solid food for the baby, you know, feeding them with the solid food and be sure that even they, you know, they gum their food and you know, they chew banana or anything that is soft enough because that is going to develop the growth and you know, jaws. The harder the Food, you know, it is as long as it doesn't hurt their gums and you know, playing with their mouth and you know, sucking on their blanket or these are all develops the neuro, what we call mascular, what we call development and the jaws and muscles and tone the muscles. So and now what about if we see the patient that already is too late, they have a small jaw and now as orthodontics we need to do something about it. So Kelly, I think that that's the part that I like to you know, share some maybe cases and.

Yeah, yeah. So I'll let you give you a moment to pull those up. And anybody who is listening to this, you can also view it on our, on the YouTube channel. And we always link, we always link that and have everything connected to the show notes as well attheuntethered podcast.com because I'm sure these will be fabulous cases to view.

Sure. Of course these are the cases that we have the permission to share their information. So for example, this is a patient that. Has been already diagnosed with sleep apnea. And one of the issues that we need to understand is, is the interdisciplinary treatment. And this is not something that orthodontists, they want to take over just individually or just as orthodontists. The orthodontist or clinicians that they want to work with this population of patient or early treatment of sleep apnea or functionality of the mouth, they need to be open minded and they need to expand their area of expertise. Meaning that they should be comfortable to work with ent. They should be comfortable to work with the sleep doctor. So and sleep doctor, you know, diagnosed this patient with the sleep apnea and it's kind of more severe form for his age, but at the same time doesn't have any adenoids or tonsils. So now we need to be aware of this that you know, if by any chance at this age, two and a half years old, although you see that, you know the jaws are not significantly narrow, the upper palate, you see that is a little bit narrow. Although in our understanding as orthodontists we don't call this necessarily very narrow. But then is the is I just don't, you know, I don't rely on the measurements or linear measurements because is the ratio, you know, in my understanding is that the ratio of the size of the tongue versus the arch width meaning that and you see it here a little bit here that the tongue it seems that is barely is fitting in the, you know, between the arches. So patient has a little Bit not that his tongue is large, is the arches are narrow for his, you know, size of the tongue. So and then on the other thing that we know that on the other side of the palate is the nasal cavity. So we used to think that, okay, what we see is palate is wide, patient has enough spacing. Will the primary spaces are there. We have ample spaces in the lower one. And what do we do with these cases? Because what do you want to expand, you know. But now we know that if you don't expand the gear of these patients, what happens is that the tongue does not have room and you see barely in this area. If you can see the arrow here, does not have tonsil. And the tonsil or adenoid. And the airway is narrow. And the result, the cause of it is, although he's not biting completely done is because of the tongue doesn't have room and is pushing back to the airway. And I'm going to show you the airway of the patient how small it is. So this is a educated ent that now that doesn't have the opportunity to get the adenoid or tonsil out, then refer the patient to orthodontist or pedodontist. So now we need to be also aware of the fact that this population of instrumentation, they call it myofunctional appliances that we before we didn't pay attention to them. But these are important especially for this population of patient because one of the things that we need to do with them is that make them nasal better. So this is a perfect time that when they come to the practice, start with this, gain the trust from their trust. So don't jump in and put expander in their mouth because then they are on age 2, 3, 4. So it's going to be a little bit overwhelming. We need to have their acceptance and permission before we go and do something fixed in their mouth. So this is a removal. And meanwhile my functional therapies start can work with the patient to develop the tone muscle, neuromuscular tone of the muscles. These appliances stay with patient two or three months. And also is going to be a good prevention for the next stage of treatment because now we start expanding the jaws and it start with the lower one because the lower one, the lower arch is not going to be skeletal expansion because mandible is one piece. The mint synthesial joint at age one is already closed. So although I'm going to show you cases that we can open it. But at this age, you know, this is the expander that we Developed it's very easy bonded. Now we have a printed form of this that is much, much easier. But they don't need. This is the appliance. This is called apnomed expander system that SML makes and is available to everybody else. But you can use even Bandit. You know, if they can use the small band on the expander, this makes it easy because everything is bonded and you know, easy to install. But if they can ask the patient to bite on the band and Bandit, that's another option. So we start expansion of the lower jaw very gradually. And then that takes about two or three months because it's going to be dental expansion. Meaning one turn Monday, Wednesday, Friday we take the weekends off. So it gradually developed the lower arch. And then now we see that you can notice that how wider is the lower arch compared to the upper arch of the patient. So definitely lower one is wider than the upper. Now remember I mentioned to you earlier startup those myofunctional appliances. You know, there are different type of it, early start, earlier start myo brace or different kind of it and wearing them at night time, it is going to help not breaking these appliances. Because the population of patient that they have a sleep paroxysm, sleep apnea. There are heavy clincher and grinders. The science shows that grinding and clinching is in children. Almost 100% is airway related. In adults, not 100% when they clinch and groin. It can be psychological, it can be function of the masticatory system. That is not right malocclusion and sleep apnea. But in children we know that almost 100% of these patients that they have clenching and groining, they have a sleep apnea also. So they wear the myofunctional appliance so they don't break the appliance. Now we start with the upper one. So this is another abnomed expander system for upper one is the bonded one. And then this is a rapid. Because now we are dealing with two pieces of maxilla that we can do it rapid expansion. Meaning that twice a day expansion for about a week or two. And significantly is going to in matter of two or three weeks, significantly we expand the maxilla and mandible of patient. We understand that on the other side of the maxilla of course is nasal cavity. Remember in earlier I mentioned to you that why do we expand the palate of the patient when it's almost okay? Well, the reason is that when we expand the palate, we expand the nasal cavity. And that's the beautiful thing that we can do to, you know, because another concept that it is important and is called sterling phenomenon. Meaning that if he understands that back to the X ray of the patient. So is a physiologic physiological law and a mechanical law that, you know, if you have a very stiff tube, nasal and we have the flexible tube, pharyngeal muscles and environment and then the suction of the air by, you know, lungs, the narrower this stiff tube is, which is nasal area, the more collapsible this flexible tube is going to be. So it is not just matter of getting the mouth wider, is making the nasal cavity wider. Because if you make the nasal cavity wider, the sterling phenomenon that we call is going to be bypass. The degree of the collapse of the airway is going to be much, much reduced. Of course, it's a multifactorial. I have introduced a classification which is good for the orthodontist and dental community. Meaning that constriction of the nasal cavity behind the palate, behind the tongue and below the tongue. So we need to start from the nares and from the nasal cavity and expand that. So the upper expander is orthopedic expander. Expand the upper one. And then of course expansion of the mouth is going to create proper room for the tongue forward from retropalatal and behind the tongue. So as a result of that, if you look at the palate of the and jaw of the patient and this is before and you see that, you know, this is the daytime X ray and you could not see any airway. And this is what we develop later, unfortunately, when we did the sleep study, his apnea completely manage. And still they're coming from Houston to Seattle to see us. And you know, so one of the things that it was about this patient and Elliot, you mentioned earlier, was a deep bite. This population of patient that they have deep bite is a multifactorial. When they clench and grind because of sleep apnea that caused the back teeth, they have stopped. The occlusal planes of back teeth is like a stop, but the front teeth, they don't have any stop. So when they are clincher and grinder, the front teeth kind of move and deepen the bite of the patient. But at the same time back teeth, you know, so they can reduce the lower facial vertical height. But the deep bite that is creating the deep bite and lower anterior teeth hitting against the inclined planes of upper anterior teeth is going to distalize the lower jaw. And these are the population of patient that the occlusion we call it is more when they chew is distalizing. Every time they chew, distalize and push the mandible back. And that is going to traumatize the joint of this patient. And the joint of the patient at this point is going to be traumatized. They're not going to complain about TMJ problem, but there is going to develop the condition that is called osteochondrosis. Osteochondrosis is slow down the growth of the condyles. And if the condyles of the patient start slowing down because of this split bite, then the mandible is not going to grow. So if you don't take care of this deep bite early enough, there is no way that the success for growing the lower jaw is going to be successful. So deep bite is one of the things that we need to address. Now the other concept is mouth breathing. And what is this side effect of mouth breathing? In the normal situation when the mouth is closed, tongue is the dentition and dental archers or sandwich between the pressure from inside from the tongue and from outside from buccinator muscles from outside. And there is an equilibrium that, you know, the pressure from inside from tongue should equal, you know, to the pressure from outside. Now of course this is multifactorial but we know that the ones that don't mouth breathe and they cannot breathe their nose. And constantly the mouth is open. Not only it can create the, what we call increase the chance of sleep apnea, but also the pressure of the cheek muscles and vaccinated muscles is going to push the upper jaw and make it a little bit narrower and usually bilateral. But sometimes, you know, patient prefers one side so they become, you know, they develop crossbite. So cross bite is one of those red flags Haley, that right away we need to address these because you see this little 3 year old patient that is referred by one of our good, you know, great what we call medullas and you know, what we call the feeding trainers that you know, she understand this concept and then refer her, you know, a grandchildren for this problem because she saw that she's mouth breathing and she has this cross bite. And what is the cross bite, what it can do? The research done at University of Washington a long time ago with the help of group of of course orthodontic residents under supervision of Dr. Jundef at the time he was the chairman at the University of Washington orthodontic department with Dr. Kennedy at British Columbia University. They noticed that patient that they have cross bite significantly on the side of the cross bite can impact the growth and development of the condyle on that side. And the condyle. Early damage of the condyle, it can create significant facial asymmetry as a result of that early treatment of these. How early? H3, H2. We need to correct this. We develop this appliances another form of abnormal expander system. You see that the cross bite is on the left side. Although patient is biting. It shows that the crest bite is this, but is repositioning to the easier part. The cross bite of the patient is on the left side. So this by attaching the front teeth, it creates maximum anchorage on this on the left, on the right side of her mouth. And then very gradually with dental expansion of one turn, Monday, Wednesday and Friday, slowly we push the upper jaw out. Upper teeth out, not jaw, upper teeth out. And then we make these unilateral crossbite to bilateral crossbite. And then we remove the anterior part of these. Now we are going to do the rapid palatal expansion. Now we are in orthopedic zone and we are going to do the rapid meaning that two turn a day and you know, every day and in matter of two or three weeks we are going to expand the maxilla of the patient rapidly and we are going to over expand. You see that how the upper jaw is more expanded because we are over expanding the palate or the tongue posture up on the roof of the mouth. And also at the same time is the nasal cavity is going to be expanded. The beauty of this expander is that after the expansion now you're going to wait about three months. So the distraction that we did on the palate is going to solidified and that's. We call it consolidation for three months. So the bone is going to get consolidated. And then very slowly, slowly, slowly we are going to, you know, retract and reconstrict the upper because the lower one is not the. She has also the lower expander. So this is the. You see that hobby corrected the unilateral cross bite, then orthopedically expanded the upper unilateral cross bite. I recommend that we start with upper, make it bilateral and then start the lower one. So at this stage, lower one is very, very slow. As I mentioned to you, one term, Monday, Wednesday, Friday and then both upper and lower are expanded. But the lower one never can get to the extent of the correction of the upper because it's a dental expansion. Upper is orthoped expand expansion. So before removing the upper expander we are going to, after three months consolidate consolidation period. We are going to retract or constrict the dental again navi. With this appliance we can reverse this and then very slowly move the teeth, constrict them and bring them to the lower dental arch before removing the appliance. That's why the beauty of these bonded expanders are versus the removable expander can work depends on the cooperation of the patient. If patient two or three years old and cannot hold it in the mouth, so the bonded ones are better. And you know, so then the arches are coordinated. Nasal cavity is overcorrected, palate is corrected. But the dental arch is not too wide and doesn't create telescopic arch. What we call now what we do with this patient. They're going to be under supervision at this point. They can use the myofunctional appliances at nighttime as a retainer. And you can see how much expansion of the airway. I need to emphasize that just having the airway Lord. Does not mean that the sleep apnea is gone. We need to understand, based on the research that it shows patient can have a huge airway problem and the presence of that sterling mechanics and mechanism that I mentioned to you patient even with huge airway on the X ray they can have narrow nasal cavity and still develop sleep apnea. So we send the patient for the sleep test and eventually we notice that, you know, sleep apnea is under control. This material, if audience are interested to read about this is was published under the. What we call the concept that is teledontic telekinetic technology in the. Is the. In orthodontic product magazine and I believe it was March of 2021. March of this material was published. Now let's talk about this telenulting telegenetic. I mentioned to you the issue of that, you know, the jaw of the patient is small and the lower jaw is small. The upper jaw is within normal limit. One of the things that if we can change the concept of the traditional orthodontics that, you know, again, orthodontic is the most powerful area of dentistry to treat this population of patients. But then we need to understand the paradigm has changed now. While ago we were thinking about just making the teeth straight and cosmetically. Now this is not just the function of the jaws is function of the airway. And anything that retract the teeth back it can negatively impact the airway of the patient. Not on everybody. But that's a epigenetic factor. If we have restrictive mechanics, meaning one of the things that we used to use in orthodontic that was headgear today is not used as much as. But at the same time we call it headgear effect that don't use anything that has a headgear effect. Pushing the upper jaw back to the lower one. Maintain the upper jaw there, even grow it and develop it more away from the base of the skull to increase the airway volume and then encourage the lower jaw also to grow weight long enough. Because the growth of the lower jaw sometimes follows the systemic growth curve and we need to wait longer so the larger group. So at this point we corrected the transfers relationship. And in this concept transfers one is first because establishing the nice airway. Now for the lower one. We wait and wait for the genetic influence of the, you know, pattern of the patient genetic influence that they have. Also by removing the trauma from the condyles, they don't clean shang grind that much. So hopefully the mandible resume to grow normally. Now there are a lot of concepts right now to describe this idea of non restrictive orthodontics. So I know my good friend and colleague Dr. Buett has the concept that non constrictive orthodontic. That's great idea. Or Dr. Kahn, another colleague of mine, he calls it forward pedantics. Meaning that do anything that you do to advance the jaws forward is a great idea. So the concept that we adopted it was not accidental because in 2019 a group of scientists actually it was the American association of Orthodontic meeting and group of scientists, including Dr. Gimina in 2019 gather and they came up with the white paper for the whole orthodontic community. In that white paper they indicated that yes, sleep apnea is the problem of dentists, especially orthodontists. And orthodontists are the best, the best modality to treat this population of patients. In that white paper also there was indicated that not everybody's jaw is going to grow normally and is a backup option. And that backup option is a surgical option, but is contrary to other orthogonal surgeries. Meaning in this option they do not bring the jaw of the patient back. They don't set the mandible back, but is the upper and lower jaw forward surgery forward. And it's called telekinetic surgery. The concept of the telekinetic, meaning that the type of orthogonal surgery used for improvement of the airway bring both jaws forward surgically has been there. The concept that, you know, how developed the jaws has been always in our mind. And we were working on that in 2017. They asked me to present this material to group of orthopedic scientists and physicians, because I was treating population of patients that are obese, overweight, with significant pelvic problem osteoarthritis of pelvic lower back and knees. So and they were interested that how as orthodontist I can bring the sleep apnea of this patient corrected and address when orthopedics is working with their what we call system or healing stem cell technology, healing their knees and lower back osteoarthritis. That group. And in that presentation I use the term that, you know is telekinetic surgery. And there were a group of scientists also from John Hopkins University in that group. And right away it kind of light bulb went on and they came up with this, you know, and they invited me to write a chapter about this concept. And in that chapter we developed the term teledontic that goes hand in hand with telegenetic. Teledontic and telegenetic are non restrictive orthodontic and orthogonal procedures that everything is for expansion and growth of the dentition and jaws away from the base of the skull. And practically non restrictive orthodontic. The advantage of it, you start as early as possible. The instrumentation that has been developed can support this. And this concept was published in the book that they that was Metabolic Therapies in Orthopedic. They asked me to write a chapter about this and now it's becoming a book that hopefully soon. So the concept of teledontic, telegenetic paleodontic is different and what we call is just different orthodontic, that is try not bringing the teeth back, not pushing anything back and restoring the airway and functionality of the masticatory system and face. So when we look at this patient, for example, is a little bit older. The same concept is going to be orthopedic expansion of the palate and development of the lower dentition. So I'm going to introduce another concept and earlier I mentioned that. So in our the teledontic telekinetic approach or technology transfers is first, because with transfers we can develop the nice nasal cavity, nice palette for the room inside the mouth, out of the airway for time. But then the mandible of this patient is small. So the traditional orthodontics, unfortunately are orthodontists today. They are very, very intelligent about this. So they are a little bit more careful not using appliances that they have what we call headgear effect. A lot of functional appliances that are out there, not. So it's fine. It's bringing the lower jaw Forward and they use it on temporary basis for correction of the airway they call it. But at the same time another thing that American association of Orthodontists did. They did a 10 year research project on all oral appliances. And that oil appliances like herbs appliance also is a functional appliance, is a orthodontic appliance. There are a lot of them and I don't want to mention any other name because somebody developed those and I don't want to badmouth them. Herbs appliance has been there for a long long time. Herbs appliance is something that they use it for managing sleep apnea in adults. But is a functional appliance that use for the children. Also the research done with orthodontics and published in American the Journal of American association of Orthodontics showed that that type of appliances they have some side effect. The side effect could be posterior open bite. Anterior open bite. Upper teeth are going to be retracted back because it has a orthopedic and it has a restrictive and holds the maxilla there or bring the upper dentition back. And that's something that the group of us that we are treating sleep apnea, you know either is forwardodontics or non constrictive orthodontics or airway orthodontics. We don't appreciate those type of appliances in our system. So this patient is wearing the. Another appliance that we developed is called Apno Thin which is a variety of apnoden which is the FDA clear. This appliance for adult is the FDA type 2 medical device for managing sleep apnea for children. As a functional Appliance is type 1 FDA clear medical device. So just growing. And this is the early version of the apnutine. Again is generated made by SML Space Maintainer Lab and is type 1 medical device. And the advantage of it is that with the mechanosensory activation stimulate the lower teeth. Lower jaw position forward is not holding against upper teeth. Holding against lower teeth and hold the jaw forward because it can retract the operator of the patient. When we go with this. And we need to have patience because now we are following the growth what we call capability or genetic growth capacity of the patient. We don't retract. And then we are going to eliminate what is called those trauma that is impacting the condylar growth. Remember we manage that and bring that under control. Every night patient wears this about 11 to 12 hours. And they're going to wear this within visaline. So that's the Beauty of it. So it means that they can wear this appliance. Patient is wearing Invisalign when they are wearing the apnutine starting age 8. So now we are going to wait for patient to grow. And depending that how fast they can grow, the airway is going to be enlarged. Because in the stage one of the treatment, we expanded the palate, time came forward and airways fine. The maxilla is not back. The mandible gradually, gradually grow back to normal. This type of population of patient, based on my experience, now we have a good chance of 80 to 90% chance to get them out of the a condition that we call it Class 2 skeletal. Severe enough that needs any surgical orthogonal surgeries. This patient, you see that it still has a tonsil because they refuse to remove the tonsils. This is a new research that shows that this population of patients, if we manage sleep apnea and sleep apnea is okay. Dr. Yoon at, you know, from California and Dr. Bakker and group of other orthodontists, they just did their new research and showed that if in this population of patient we expand the maxilla and improve the airway of the patient, the tonsils and adenoids can shrink. So that's a good news. Patient doesn't want to have the surgery. If we expand them non surgical, then those tonsils and things, the adenos, they can shrink. So that's less surgery, the better it is. So she is growing, the mandible grows fine. This is another case. This is another variety of the appliance that is spring loaded. Because one of the things that we need to be careful when we expand the upper jaw, the upper front teeth that they can retract back. And in philosophy of teledontics, we don't want anything restrictive and come back. So that way this appliance, it helps to maintain the upper front teeth where they are. So the lip of the patient is not going to be compromised in larger the airway without compromising the aesthetic of the patient. Still we are in orthodontic zone. And orthodontic is in the beginning was initiated as a cosmetic philosophy. Now we are bringing the concept of function of the masticatory system, airway system or this whole systemic health to it. So but we cannot neglect the cosmetic of the patient at the end. Teeth should look great. Profile of the patient should not be compromised. Because most of these expansions that they do unfortunately is not done right. And then the fronted can retract back and create deficient upper lip. And so this is another case before and after now earlier I talked about the epigenetic. So I want to show this case to prove my. You know, that not proving, but show that concept. This is a patient that unfortunately when he was through the treatment he suffered from restrictive orthodontic treatment. So not on everybody, but on this susceptible population of patient. We should be careful not using what we call restrictive orthodontic treatment. And this patient had one of the forms of restrictive orthodontic treatment. He removed his first bicuspid and retracted everything back. He has AHI severe sleep apnea apnea, hypopnea index of 80. But when he was growing also he had had this problem of sleep apnea clinching and grinding. His lower joy is small. And then this is his son. His son also has the same epigenetic problem. Meaning that he has genetically has good growth potential. But epigenetically because of a sleep apnea, clenching and grinding, creating trauma to his condyles every night and slowing down the growth of the mandible. Not only the mandible, as you know, I'm showing here, does not grow but damaging it. It can kind of create a retrusive position of the mandible. And you know, mandible does not grow or actually after in adulthood can retract and creates damage. So but what we call by encouraging the system managing sleep apnea by early expansion of the jaws. That's why transfers for us and airway is number one. We can grow the. Grow the jaw of this patient back to normal again. He has been wearing the apnutine during. During the. After the expansion. You know, you use the apnutine, waited long enough to grow the growth the mandible. And I'm not going to emphasize if you can find any appliance, any functional appliance out there that is non restrictive, does not have a headgear effect, doesn't bring upper job back or could climb the lower teeth. This appliance. The way that it does is gentle touch of the appliance with the lower incisal teeth activates the neuromuscular system. So it's a neuromuscular activation to bring the mandible forward. And this is the airway before and after now. And the good things that they go to college now they're smart. I showed you some cases. Hopefully I need to go through this. And this is his brother the same thing. And this is not just on one or two patients. The philosophy of this teledontic telegenatic is that we do the non restrictive orthodontic the upper jaw in significant number of population of patient. As Dr. Jim McNamara showed. And recently Dr. Bill Hang supported that idea. The upper jaw of the patient is normal. Mostly Dr. Mew also talked about this and he was into developing the upper jaw of the patient and bring it forward. So if upper jaw is normal, especially in Caucasian patient, the lower jaw is small. So we encourage the growth of the larger. But we need to have patience. So patient grow through the growth spur and finalize the growth of the mandible before we finalize the treatment. And don't jump in to bring the operative back to the lower teeth. So these are population of patients that you see that. But if the earlier we start, the better the idea is going to be and is unrelated to the race. These are different patients with different ethnic background that you see that it works. Nasal cavity expanded. And the jaws, they grow depending on the capability and the capacity of their. Because some different ethnic background, they have a smaller jaw, some they have a stronger jaw. But the goal is improving the area of them making the arches very wide. As Dr. Bill Hang explained, the tongue goes to the roof of the mouth. Dr. Mu also supported this idea, which initiated actually by Dr. Meu. And you see that these jaws actually did grow tremendously. And it's not just Joseph Yousefian doing this. It is anybody that is capable to use these appliances. And the right concept of this. Now, this doesn't work for everybody because sometimes we get the population of patient that is too late. So. We should have a backup option. So it means that in pediatric treatment, early treatment, orthodontist needs to have a backup option. And the issue that I'm hearing often they say that, okay, orthogonal surgery is too drastic, is too invasive. Well, let me show you the last two cases. Then we are going to come back to this concept. This is a patient. The reason that I'm introducing this, you see that he and his brother, they had severe crowding. As orthodontist, I learned as soon as I see these, I said, well, there is not enough room. Although we are educated enough that we know that we can expand the maxilla, but then mandible. What do you want to do about it? And one of the options it was removing teeth to make the rest of the teeth, you know, balance and art form. Okay, now, but we have a problem with this case. Has a sleep apnea. Dad has a sleep apnea. And that which is great. Aerospace scientists very smart and early age, mid late 50s, early 60s develop one of the side effect and side effect of sleep apnea. Comorbidities of sleep apnea. And that's stroke, which half of the body paralyzed. So if this patient has sleep apnea and his genetic susceptibility to go to that route, we need to do everything possible to avoid using restrictive technology. So as a result of that, we started expanding his palate. So he's about age 13, 14. Maxillo did not expand very well. So that's why you need to be ready to jump to the next one. And the next one is mse. The MSE technique, which is maxillary skeletal expansion that we have developed since is more calculated. It can control the what we call the unilateral or bilateral cross points very well. Because one of the problems with MSE is uncontrolled movement of the teeth. Because usually they put it in the palate teeth, they don't have anything on them. And it can go unilateral or bilateral. I mean unilateral cross bite. And when it goes unilateral cross bite. That's why some orthodontists are afraid of this. Because in some susceptible population of patient facial asymmetry, maxilla can happen and it can impact the vision of the patient. They can develop double vision. So this system is more predictable. So not only we expanded his maxilla, also we expanded the mandible in between in the symphysial area. What is the advantage if we expand the maxilla? Only without the expansion of the mandible, we cannot expand too much. But if we expand the mandible and expand the maxilla, we can double the expansion of the maxilla. I have degree in anthropology and my master in MA is Master in anthropology. I know. And I did research on Adeno Indians 2000 years ago Living in Ohio Valley Haley next to Ohio State University. So in those Adeno people, Indians, when you look at, I looked at a skull of this patient, they had huge mandibles and wide arches. All right, with those wide arches, I don't know how many Adeno Indian, you know, people, they could suffer from sleep apnea. But anyway, we create this expanded the jaws. Look at the upper lip. See how supported it is, is not retracted. And this technique, expansion of the lower jaw. We call it DAME Distraction assisted nasal maxillary expansion. The upper one, micro implant assisted nasal maxillary expansion. Because we are not just expanding maxilla. So I don't call this just MSE is the nasomaxillary expansion main or the lower one. It is the DAME Distraction assisted mandibular expansion. And this is called telekinetic surgery. I Invite everybody to look at this differently. We are in different paradigm. This is the airway environment. So we cannot stay with the old way of thinking. The new way of thinking is that if white paper of American association of Urbanities introduced the concept of the telegnetic bring maxilla forward, mandible forward to improve the airway. So any surgery that we do for expansion of the jaws, we should think about is another stage of telekinetic surgery. Telekinetic surgery, move the jaws to distance to open up the airway and jaws. So this is a telekinetic surgery, expansion of the mandible. Right. So how important is sleep apnea? Ellie, earlier when we were talking about this, we talked about ADD adhd.

Yeah.

So let's talk about it. Why early treatment is important, why supervision of this patient are important. So I want to show you two cases. This is a case that came to me, you know, and my dear, one of the Most knowledgeable colleagues, Dr. Norm Chang and his son Ryan Chang, they referred this patient to me. 1112 years old. This is something that we see every day and used to see as orthodontists. Before, as orthodontists, we were looking at it differently than we are looking at it today. So the kid is bothering everybody, teasing assistants, going chair to chair, look at inside of other patient mouth. And everybody's annoyed when he's coming to the office, nobody wants work on him. But we did it. But we did it orthodontically. Just used the two by four appliance, did not expand the mandible. And about the time that I was getting educated about sleep apnea, he unfortunately disappeared. Very nice family, dad was supportive. But unfortunately, somehow they disappeared from treatment. And then this is after phase one, just two by four expansion. And he was no expander, just two by four making the teeth straight. And he was missing a central here, a lateral tooth. So then suddenly he comes back at age 17, 18. The palate is narrow, the mandible is narrow. And at the time he had, you know, severe sleep apnea and severe sleep apnea, meaning for 17 year old still ahi was 17 ahi. So he's severe. So he comes back. And something else is there the reason that he was so mischievous and you know, out of control. He had ADD ADHD is not his fault. He's suffering from sleep apnea. And side effect of that is, you know, it can be sign, sign and symptoms of ADD adhd. Unfortunately, we lost the opportunity to treat him when the brain was doing this. Active growth and development this is something that Dr. Gimino opened my mind to it that early treatment of the these cases because you can reverse the ADD adhd. So when we came back, you know, again with the dame distraction assisted mandibular expansion. We expanded the mandible as part of teledontics. Telekinetic opening the space, expanding the jaws away from the base of the skull. So it's necessary in order to expand the mandible. We put the tooth back as an implant. So we did that, expanded the mandible. And then he had telekinetic surgery. So the first one, which is expansion of the mandible was stage one telekinetic surgery. Then we did the stage two, which was stage two of telekinetic maxillomandibular advancement. Open up the space intelligent. We put the tooth back, we don't take the tooth out. So that way expanded the palate, expanded the jaws. And his severe sleep apnea improved completely. Then I was seeing him and then suddenly he disappeared. And we knew that at the time that I was seeing him, he was talking about being tired of the school. He was in the 10th or 11th grade. He was getting teased a lot, you know, because of his small jaw. And his classmates, they were not very kind to him. And unfortunately we need to be aware of it. And I explained to you, you know, in the next case. So, you know, he just dropped out of the school. A lot of our dropouts from the school, they are not. They're. They're intelligent. But at the same time, this environment and sleep apnea, there's something that creates for it. They cannot remember, they cannot apply their brain to full capability that they have. And then they get teased and then they get what we call pushed away. And they decide that, you know, this is too fast, I cannot catch up, I'm going to quit. So he quit school. And he was telling me that later he came one day and his hands, they were oily. And he said, I'm working at mechanic shop. There is nothing wrong with it. Not everybody needs to pursue the what we call academic. You see that whole airway is large. And he came back 17, 17 years later, lost his retainer. He showed up and diseased his teeth 17 years later with no retainer. So and still is stable. The only regret that I have, I wish that we had the opportunity maybe to start earlier and finish him earlier to take care of sleep apnea earlier. Because still he's a sleep apnea. AHI is one which doesn't have. It is better than five is Normal. And this is better than this. So the early treatment is going to prevent this population of patients suffer from ADD ADHD that not everybody suffers so significantly from it, but impacts the life of some that are susceptible. Not everybody. And comes this case now I remember this. I learned my lesson. This comes a small job and is six, is nine at the time, was eight years old. This is a kid that when was growing up had a lot of issues, you know, clinching, grinding, you know, and get tired of school fast, get tired of sport fast. I knew something is there, so I didn't do anything. The palette is white. Why do you want to expand? This palette is white. Look at these spaces here. How do you want to. If you expand, what do you do with it? So we just wait, waited, waited, didn't do anything. And of course I'm nervous, but I know something else is there.

So.

But then the problem starts showing itself. Meaning that school calls parents and say that, you know, we need to have the meeting. And they say that this kid is disruptive. First of all, he was a B student and now he gets to the point that C, D once in a while, F. So the teachers, they complain that his disruptive to class, his grades are, you know, dropping. And they recommend that, you know, additional schooling, special schooling for him. And as you see, he's gaining weight a little bit and he's getting teased. And at that point still we don't know what is going on. And then suddenly he had a large tonsils. Then Suddenly about age 12, 13, another problem with this population of patient comes. He becomes significantly obese. One third of population of children in industrialized countries that unfortunately is very unhealthy diet, high calories. When they have a sleep apnea, the urge for eating fast, sugary food, sturdy food, make them obese, overweight. He was diagnosed with addh. They put the mark of adhd. He had what we call acid reflex metabolic syndrome, high blood pressure, high cholesterol hypertension, which was the duplication of his grandpa. At age A.D. he had the same problems and died from heart attack. So now this becomes a emergency. He has severe sleep apnea, is too late. We are not sure what to do. That's why we didn't do anything. Just wait. And then at age 18, has a sleep apnea. We resume didn't bring the upper jaw back. But the thing is one of the things that happened during this three, four, five years of schooling and unfortunately students not to be mean, not understanding the concept. Now he's start getting teased because of weight, because he's slowing down on his education because he doesn't have good grades anymore. And. And they are not very, you know, kind students. And just reminding him that why don't you don't think about the college. Even the advisor of the school recommended to them that is not a college material. Think about other work. And that's why this population of patients are ready to snap and drop the school because they feel I'm behind and I cannot catch up. So they are going to drop off of this escalator that is going fast. Is like when you go to airport and people they get on this walking escalator that is making the people going fast and some cannot catch up and they go backward and get out of the schooling system. He hated the school, he hated education and sport. He was not happy about his body going swimming. So that's how the decline happened. They broke his heart. So and that comes, you know, we did the surgery. The sleep apnea is gone. The issues of the early ADD ADHD noise subsided. But one thing that was hurt the most was emotionally was heard. And they dictated in his mind that if you are getting the low grade is not because you don't remember because of sleep apnea, because you are not smart. So they hacked in his mind that he's not smart. And that part was hard to bring it back. He was brainwashed that you are not going to succeed. And I'm telling you based on my experience and literature shows one third of population of youth in industrialized countries that they suffer from this problem. They build up. The majority of those drop out, drop out students from the school. So we shouldn't leave them alone. There is a reason for it and sleep apnea could be one of them. So but correction of the sleep apnea improve it. The guy becomes very, very smart. Actually too smart. He goes to the college that they told him don't go, you're. You're not able to go. He. He just didn't listen to it. And of course his parents also they told him that he's wrong. Especially his dad anyway corrected this. He got a scholarship at the school. He went to university. He did very well. And he now he has his businessman and a startup company. He's a sleep apnea is fine. And since we did start early and stay with the case and manage his sleep apnea and treat it this population of patient they can reverse the course of their life and become successful. They can change their starts. That other hand is going to go downward. And now he's very, very successful businessman and he's my son, and I'm so proud of it. And I try not to cry every time that I present this case. It just break my heart when my Ryan was growing and how much he suffered, so. Ellie.

Well, he has you to think. Yeah, he's got you to think, because it's an incredible story. And, you know, it's. It's actually a story that we're hearing more and more of. And you talked a lot about the psychosocial impact on children. And it's, you know, there's a lot of focus, I think, on the impact when children are in their first seven years of life and how, you know, the brain is so easily molded, but it goes way beyond that. It goes into early adulthood when people are still so impacted by extreme external input and hearing what others say to you. And, I mean, myself, with adhd, I did manage pretty well through most of school until I got to college. And when I got to college, it kind of all fell apart. I went and I got tested. They said, oh, well, you have a high iq, but we're not going to put ADD on your medical records, but you have add, so here's a Ritalin prescription. And I was like, how does that help me? So I took it. I got through grad school, undergrad, grad school. My grades were great. I hated the stuff, and nobody looked at my airway. I went for my own sleep studies. Nothing came back positive. You know, everything was like, oh, you're fine. You're fine. Until I fell deeper into this space and learned about UARS and got diagnosed with that, and, you know, the rest is history. But, you know, I thank you for sharing his case and your experience and everything that you've learned from it, because, you know, we can see your passion behind it. I'm sure that it's extremely rewarding to be able to share this case, what you've learned, and even the vulnerabilities of being a parent and going through all of this with your own child. It's incredibly touching and moving. And thank you for. For sharing us, and thank you, Ryan, for letting your father share your story, because I think it really. It helps so many more people than you, you'll ever probably realize in your life.

My pleasure. Yeah, that was a great opportunity. And, you know what? Not we have. I think that this is. This is something that, you know, Hayley, that is a pandemic. We have a big pandemic that, unfortunately, this pandemic of the, you know, coronavirus mask it completely. The sleep apnea, you Know that is a pandemic because of the evolution of the face of the humans. The jaws are getting smaller. Now we have. We need to have an army of people. And this army of the people or clinicians start with mom and pop that they need to be educated myofunctional therapist or the feeding specialist and coach. These are all they need to be part of this team. So the book that is going to come out about teledantic, telegenatic, you know, is going to be for population of the army of the, you know, nutritionists, obstetrician, feeding coach and myofunctional therapies, orthodontist. These all they need to work together and then fight this enemy that is as a pandemic is impacting the human growth and development.

Absolutely. And I love that we promote a major collaborative effort because that's really what it takes, especially with these cases and these individuals that we all treat so. Absolutely. And thank you. Thank you so much for your time.

Thank you very much for the opportunity.

We'll put it in the show notes and everything. But you know, tell us where they can find you, where they can reach you. You mentioned the book. Where can they find that? Would that be on your website? Tell us about that for a second.

There is a website about teledontics. They can go on that. And hopefully the book is coming because the book is going to present actual cases. So each chapter is presenting a finished case, treated case. That's why has been a little bit longer. Covid kind of pushed it back a little bit. Patient, they don't show up for their appointments. So we are waiting for the last few patients to finish them. And then the book is going to be coming hopefully, hopefully in 2023.

Fabulous. Well, we know we can go to dryusepien.com to find you again. That'll be in the show notes and keep us posted on when the book comes out so we can share that with everybody. And thank you guys. Thank you and your son for sharing his case. Thank you so much for joining me today.

Thank you very much, Hayley for the opportunity. Take care. Have a nice day.

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